Get a Health Insurance Quote

The Perimeter Group provides multiple ways to get an insurance quote. You can get an instant quote on-line to compare multiple carrier rates. Or, you can fill out our on-line quote form and submit it to us to have our staff look at an even greater number of carriers to get you the best rate available among our carrier roster. Finally, you can contact us via e-mail, phone or fax to start the quoting process.

In order to get the most accurate quote for insurance it is important to provide all of the information requested as accurately as possible. A good information resource is your current carrier insurance declaration pages that detail your coverage levels and other key information about your vehicles and properties.

General Information

Legal Name of Business:
Contact Name:
Business Phone:
Best Time To Call:
Contact E-mail:*

Type Of Business

Type Of Business:
Standard Industry Code (if known):
Number of Full Time Employees:
Number of Part Time Employees:
Give a complete description of any type of hazardous / dangerous duties performed by your employees:

Current Group Health Insurance Information

Company Name (not agency):
Please provide a brief description of your current Group Health plan:

Benefits Desired

Major Medical Dedictible
Dental Coverage:
Disability Insurance:
Group Life Insurance:
Optional Pregnancy Coverage:
Supplemental Accident:
Prescription Discount Option:
PPO Option:
HMO Option:

Employee Information

Employee Name:
Employee Date of Birth:
Employee Sex:
Dependent Status:
Employee Name 2:
Employee Date of Birth 2:
Employee Sex 2:
Dependent Status 2:
Employee Name 3:
Employee Date of Birth 3:
Employee Sex 3:
Dependent Status 3:
Employee Name 4:
Employee Date of Birth 4:
Employee Sex 4:
Dependent Status 4:
Employee Name 5:
Employee Date of Birth 5:
Employee Sex 5:
Dependent Status 5:
Employee Name 6:
Employee Date of Birth 6:
Employee Sex 6:
Dependent Status 6:
Employee Name 7:
Employee Date of Birth 7:
Employee Sex 7:
Dependent Status 7:
Employee Name 8:
Employee Date of Birth 8:
Employee Sex 8:
Dependent Status 8:
Employee Name 9:
Employee Date of Birth 9:
Employee Sex 9:
Dependent Status 9:
Employee Name 10:
Employee Date of Birth 10:
Employee Sex 10:
Dependent Status 10:

If you were not able to list all employees you wish to cover in the spaces above, please use the Additional Comments section below or indicate that you will fax or email an additional listing.

Additional Comments

Please give any additional comments you feel appropriate for this quote. If you have additional information where there was not enough space, please enter that here.
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to provide you with a quote, and to release them from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.*